WHAT TO DO IF YOU HAVE PROSTATE CANCER: THE WATCHFUL WAITING DEBATE
To help solve this perplexing dilemma—which is being faced by increasingly more men as the population grows older and better means of detection are developed—a study often referred to as the "Swedish study" began.
In this study, a Swedish team of urologists and cancer epidemiologists came up with valuable data. They studied 223 patients identified as having early stage (grade I) prostatic cancer that was initially untreated. Symptomatic patients with tumor progression were treated with estrogen or by surgical removal of the testicles. If the tumor growth remained localized and metastases were not present, no treatment was given, as was standard practice in Sweden in March 1977 (when the study began). Later, the men who were under seventy-five years of age with moderately or poorly differentiated (grade II or III) tumors were randomly allocated to receive local irradiation or no therapy. Only the latter were included in this study. Patients who were seventy-five years or older were not treated and were also included.
In other words, a lot more men died with prostate cancer than of it Comments by Dr. Ralph deVere White concerning this study are enlightening: "It struck me, having looked through the history of this disease as reported by this study, if 10 percent of patients who had a radical prostatectomy die of the disease and 12 percent of patients who have absolutely no treatment immediately die of the disease, why would anyone ever consider having their prostate cancer treated?"
However, Dr. deVere White believes that the American experience with prostate diseases is different from that reported in the Swedish study. In Sweden, 60 percent of the study group have the very lowest stage of cancer. In looking at the American series of patients who have undergone surgery, the figure is about 10 percent. Since these were vastly different figures, I asked Dr. deVere White what his numbers were. He reviewed the last hundred radical prostatectomies that he performed to see how many of those were like the Scandinavian patients. Only 5 percent of them had that very low malignant type of tumor, compared to the 60 percent reported in the Swedish study.
"Similarly, close to 60 percent of the Swedish study patients are dead of some cause other than prostate cancer in ten years. When you look at surgery series in America, what you see is that at ten and fifteen years in close to 1,000 patients who have been operated on, only 20 percent die of something else. Again, this fact that die patient dies does not mean they did not receive the right treatment, namely none. What it does mean is if you are an average American, you are going to have a more aggressive cancer, you are going to live longer, and therefore you would be foolish to have taken at face value the difference in survival between the American series and the Scandinavian series.
"The final bit of evidence is that we know if patients go and get the cancer in the bones they do not do so well. When one looks at the Scandinavian series, even taking all of the above into account, twice as many of those people develop disease in their bones than in the radical prostatectomy series.... You are not comparing apples and apples, but rather apples and oranges if you just take it on face value."
Sweden also has a socialized medical plan, and the question arises: does the cost of surgery for prostate cancer affect the decision about the type of treatment selected? To watch and wait is considerably less expensive than performing an operation, particularly in the early stages of treatment.